Borderline personality disorder and health care utilization in
a primary care setting.
Sansone, Randy A.; Sansone, Lori A.; & Wiederman, Michael W.
Southern Medical Journal; Dec96, Vol. 89 Issue 12, pgs. 1162-1165
BORDERLINE PERSONALITY DISORDER AND HEALTH CARE UTILIZATION IN
A PRIMARY CARE SETTING
ABSTRACT: We examined health care utilization by subjects with
symptoms of borderline personality disorder. The study included 194
female subjects between the ages of 17 and 52 who were consecutively
seen for nonemergency medical care in a health maintenance
organization. Each subject completed the borderline personality
scale of the Personality Diagnostic Questionnaire-Revised (PDQ-R),
as well as the Self-Harm Inventory, which correlates with the
diagnosis of borderline personality. For each instrument, subjects
with scores suggestive of borderline personality were compared with
subjects without this disorder in regard to their utilization of
health care resources (eg, number of combined telephone contacts and
physician visits, number of physicians seen, number of prescriptions
obtained) during the preceding 12 months. Subjects with more severe
borderline personality disorder (according to the PDQ-R) made
significantly more contacts with the health care facility (ie,
telephone calls and physician visits) and received more
prescriptions.
Studies indicate that a significant minority of patients seen in
primary care settings (15% to 30%) have psychiatric disorders.[1-6]
The research literature consistently suggests that those with
psychiatric disorders use primary care services more than
nonimpaired individuals.[6-10] Studies of several specific Axis I
psychiatric disorders, including dysthymia,[11] depression,[12]
somatization,[13-15] panic disorder,[16,17] and factitious
disorder,[18] also support this finding. One study reports a
significant association between pathologic personality traits and
medical utilization,[19] but we found no study that examines the
utilization of health care services by patients with specific
personality disorders.
The current study was done to explore the impact of a particular
personality disorder, borderline personality, on health care
utilization in the primary care setting of a health maintenance
organization (HMO). Borderline personality disorder is characterized
by a veneer of normalcy in brief social encounters as well as (1)
fleeting and long-standing quasi-psychotic episodes (eg, transient
depersonalization, derealization, rage reactions); (2) chronic
impulsivity manifested as self-regulatory deficits (eg, substance
abuse/dependence, eating disorders, promiscuity, gambling) and overt
self-destructive behavior (eg, suicide attempts, self-mutilation,
high-risk hobbies or behavior, sadomasochistic or abusive
interpersonal relationships); (3) chaotic and chronically
unsatisfying interpersonal relationships; and (4) chronic dysphoria
(ie, persistent depression, anxiety, emptiness, anger).[20,21]
Again, the unique feature of borderline personality is the
superficial appearance of normalcy in transient social encounters
coupled with significant underlying psychologic dysfunction.
Borderline personality was chosen for study because of its high
prevalence in psychiatric settings (15% to 25% in inpatient and
outpatient populations[22,23]) as well as in primary care settings,
the difficulty in treating/caring for these individuals in primary
care settings, and the potential for self-destructive behavior and
medical noncompliance in these patients.
MATERIALS AND METHODS
The study population consisted of 194 female subjects between the
ages of 17 and 52 (mean age, 33.6; SD, 9.2) who were consecutively
seen for nonemergency medical care by a female family physician
(L.A.S.) in an HMO. The response rate was 97%.
Two instruments were used. The first was the borderline personality
scale of the Personality Diagnostic Questionnaire-Revised
(PDQ-R),[24] an 18-item self-report inventory that screens subjects
for symptoms compatible with borderline personality. The borderline
personality scale of the PDQ-R is based on the criteria for
borderline personality noted in the Diagnostic and Statistical
Manual of Mental Disorders, 3rd Edition, Revised (DSM-III-R).[25]
The PDQ-R has been reported to be a useful screening tool in both
clinical[26,27] and nonclinical[28] populations.
The second measure, the Self-Harm Inventory (SHI),* is a 22-item
self-report questionnaire that explores subjects' self-destructive
behavior. Each item is preceded by the statement, "Have you ever
intentionally, or on purpose. . . ." Items include "overdosed,"
"burned yourself," "attempted suicide," "cut yourself," and "engaged
in sexually abusive relationships." A score on the SHI is the total
number of endorsed items, each of which represents a pathologic
response (ie, there are no nonpathologic items in the inventory).
Scores on the SHI have been shown to highly correlate with
borderline personality* as measured by both the borderline
personality scale of the PDQ-R (r = .67) and the Diagnostic
Interview for Borderlines[29] (r = .76). A cutoff score of 5
represents an overall accuracy in diagnosis of 83.7% (with diagnosis
based on the Diagnostic Interview for Borderlines).[a]
All subjects participated in the project after their nonemergency
visit. In a quiet room on site, each subject completed a testing
booklet that included a demographic inquiry, the borderline
personality scale of the PDQ-R, and the SHI. The medical records of
all participants were reviewed after testing. For the pre-ceding 12
months, the following measures of health care utilization were noted
from the medical record: (1) the total number of contacts by the
subject to the facility, which consisted of the combination of
telephone calls and physician visits; (2) the number of different
physicians seen by the subject; and (3) the number of prescriptions
provided to the subject. All subjects had consistently obtained care
at the HMO during the preceding 12-month period. The medical records
were reviewed blind to subjects' psychologic testing results.
RESULTS
According to the recommended cutoff score of 5 for the borderline
personality scale of the PDQ-R,[30] 38 subjects (20%) reported
symptoms suggestive of borderline personality disorder. According to
the recommended cutoff score of 5 on the Self-Harm Inventory, 30
subjects (16%) met the criteria for borderline personality disorder.
The results of one-way analyses of variance comparing these groups
with regard to use of medical services are presented in the Table.
Subjects with borderline personality symptoms showed significantly
greater utilization of resources (eg, telephone and physician
contacts) than subjects who did not evidence borderline personality
disorder on the PDQ-R.
The data were analyzed as continuous variables to determine whether
an increasing score on the measures of borderline personality might
relate to increasing use of medical services. To investigate this
possibility, Pearson's correlation coefficients were computed
between both PDQ-R and SHI scores and the degree of medical care
utilization by subjects. Scores on the PDQ-R were correlated to the
number of facility contacts (telephone calls and physician visits)
by subjects (r = .21, P < .05) and the number of prescriptions (r =
.16, P < .05) but not to the number of different physicians who had
seen the subject. Scores on the SHI were unrelated to any of the
measures of medical care utilization.
DISCUSSION
In this study, participants with borderline personality symptoms
(according to the PDQ-R) evidenced significantly higher utilization
of primary care resources than those without borderline personality
symptoms. In addition, increasing PDQ-R scores for borderline
personality (ie, severity) predicted increased use of medical
resources. These findings are consistent with the majority of
studies indicating that individuals with psychiatric disorders
evidence higher rates of health care utilization. These studies also
indicate that individuals in primary care settings with borderline
personality present an additional risk of cost through higher
utilization. There may be an underlying cost for mental health
services, which was not explored in this study.
The second measure of borderline personality, the SHI, showed no
significant correlation with medical care utilization. This finding
is difficult to explain but may have to do with the nature of the
measure. The SHI surveys overt self-destructive behavior, whereas
the PDQ-R may be a measure of more generalized psychiatric
disturbance. Conceivably, at least some individuals with
self-destructive tendencies avoid medical treatment, even when
needed, as one more form of self-harm behavior. Further research on
the relationship between self-harm behavior and the nature of health
care utilization is needed.
There were no significant differences in the number of physicians
that subjects saw for treatment as a function of borderline
personality disorder. This is surprising, since borderline
individuals are characterized by their impulsivity and low
frustration tolerance. We would have predicted a significant
between-group difference, with borderline subjects seeing a greater
number of different physicians. However, the population demographics
may explain this in that the borderline subjects in this study
appear to be fairly high functioning.
Somewhat surprisingly, of those individuals whose PDQ-R scores
indicated borderline personality, 63% were married, 26% were single,
and only 11% were divorced. For those identified as borderline by
the SHI, 57% were married, 19% were single, and only 7% were
divorced. Regarding educational levels, only one individual (3%) in
both cohorts did not complete high school. Fifty percent of those
with borderline personality as shown by the PDQ-R had attended
college, and 16% had a bachelor's degree or higher. A similar
educational profile was obtained when examining those with
borderline personality diagnosed by the SHI. Again, this sample of
borderline individuals appears to be much higher functioning than
individuals from other borderline personality samples. Therefore, we
suggest that in a lower functioning population, these findings might
be even more pronounced.
Taking into account the previous studies on psychiatric disorders
and medical utilization, these findings suggest that psychiatric
disorders including personality disorders generally predict higher
rates of health care utilization. Therefore, in predicting health
care utilization patterns in populations with psychiatric disorders,
and, specifically, personality disorders, greater costs can be
expected.
We believe this is the first study to investigate potential
differences in health care utilization by patients with, versus
without, borderline personality disorder in a primary care setting.
A potential limitation in this study is the use of self-report
instruments as measures of personality disorder. The strengths of
this study include the use of two measures of borderline personality
(ie, borderline personality scale of the PDQ-R and the SHI), the use
of multiple measures of health care utilization (ie, contacts to the
facility, which included both telephone contacts and physician
visits, as well as number of prescriptions), and the recruitment of
subjects from an enclosed health care delivery system (ie, a health
maintenance organization) where utilization patterns could be
accurately assessed. Given the prevalence of borderline personality
disorder in all clinical settings, these findings are noteworthy.
a
Sansone RA, Wiederman MW, Sansone LA: The Self-Harm Inventory:
development of a measure for predicting borderline personality.
Submitted for publication.
Supported by Grant No. 93-1 from the Laureate Research Foundation,
Tulsa, OK.
TABLE. Comparisons Between Subjects With and Without Borderline
Personality Disorder With Regard to Health Care Utilization (n = 194)
Legend for Chart:
A - Measure of Health Care Utilization
B - Borderline Group Mean (SD)
C - Nonborderline Group Mean (SD)
D - F
E - P Value
A B C
D E
Diagnosis based on PDQ-R
Number of facility contacts
(telephone calls, physician
visits) 12.11 (12.12) 8.64 (7.05)
5.38